Secure Housing Intake

Please provide detailed and accurate information. This data is used to determine eligibility for the Pathway2Progress housing and workforce program.

1. Contact Information

First Name

Middle Name

Last Name

Preferred Name / Alias

Phone Number

Email Address

Confirm Email Address

Referral Source

Additional Notes

Contact Consent I consent to be contacted via text, email, or phone.

2. Legal Identity

Full Legal Name

Date of Birth

SSN

ID Type

ID Number

Issuing State

Physical ID in hand?

Do you have a DOC number?

DOC Number

Name on DOC Documents

Background Check Consent I authorize Pathway2Progress to conduct a background check.

3. Demographics & Status

Race/Ethnicity

Sex at Birth

Sexual Orientation

Relationship Status

Preferred Language

Veteran Status

Employment Status

Location Preference

4. History & Wellness

Reason for seeking housing

Address History (Last 3 Years)

Drug of Choice (If applicable)

Date of Last Instance

Mental Health Issues?

Self-Harm History?

Current Prescription Medications?

List Medications

Gang Affiliated?

Sex Offender Registry?

Arson Charge?

Preferred Move-In Date

Housing Restrictions

5. Professional References

Ref 1 Name

Relationship

Phone

Ref 2 Name

Relationship

Phone